Meat consumption and mortality - results from the European Prospective Investigation into Cancer and Nutrition.

BACKGROUND Recently, some US cohorts have shown a moderate association between red and processed meat consumption and mortality supporting the results of previous studies among vegetarians. The aim of this study was to examine the association of red meat, processed meat, and poultry consumption with the risk of early death in the European Prospective Investigation into Cancer and Nutrition (EPIC). METHODS Included in the analysis were 448,568 men and women without prevalent cancer, stroke, or myocardial infarction, and with complete information on diet, smoking, physical activity and body mass index, who were between 35 and 69 years old at baseline. Cox proportional hazards regression was used to examine the association of meat consumption with all-cause and cause-specific mortality. RESULTS As of June 2009, 26,344 deaths were observed. After multivariate adjustment, a high consumption of red meat was related to higher all-cause mortality (hazard ratio (HR) = 1.14, 95% confidence interval (CI) 1.01 to 1.28, 160+ versus 10 to 19.9 g/day), and the association was stronger for processed meat (HR = 1.44, 95% CI 1.24 to 1.66, 160+ versus 10 to 19.9 g/day). After correction for measurement error, higher all-cause mortality remained significant only for processed meat (HR = 1.18, 95% CI 1.11 to 1.25, per 50 g/d). We estimated that 3.3% (95% CI 1.5% to 5.0%) of deaths could be prevented if all participants had a processed meat consumption of less than 20 g/day. Significant associations with processed meat intake were observed for cardiovascular diseases, cancer, and 'other causes of death'. The consumption of poultry was not related to all-cause mortality. CONCLUSIONS The results of our analysis support a moderate positive association between processed meat consumption and mortality, in particular due to cardiovascular diseases, but also to cancer.

Étude de la fonction de GLUT8 sur un modèle de souris "knock-out"

Résumé GLUT8 est la première des nouvelles isoformes des GLUT récemment identifiés. Il est fortement exprimé dans les testicules et plus faiblement dans les blastocystes, le cerveau, particulièrement au niveau de l'hippocampe, et le coeur. En conditions basales, il est retenu dans un compartiment intracellulaire. Si on l'exprime en surface cellulaire, par la mutation du motif d'internalisation dileucine, il transporte le glucose avec une bonne affinité. Dans le but d'étudier sa fonction au niveau de l'organisme, nous avons créé un modèle de knock out conditionnel, en entourant le dernier exon du gène de GLUT8 par deux sites loxP. En croisant nos souris avec une souche de souris transgénique exprimant la cre-recombinase dans les cellules de la lignée germinale, nous avons généré un modèle de souris portant la délétion totale de GLUT8 de manière constitutionnelle. Les statistiques effectuées sur les premières naissances indiquent qu'une partie des souris knock out ne survit pas, suggérant un rôle de GLUT8 au niveau du développement embryonnaire. Les souris qui ont survécu ne présentent toutefois pas d'anomalies durant la croissance et sont fertiles. Elles ont des taux de glucose et d'insuline sanguins normaux. Au niveau cérébral, la structure de l'hippocampe n'est pas modifiée par la suppression de GLUT8, cependant, les souris GLUT8-/- présentent une prolifération cellulaire augmentée dans le gyrus denté. Cette augmentation de division cellulaire pourrait être la réponse adaptée à une éventuelle augmentation de la mort cellulaire au niveau de l'hippocampe. Elles ne semblent toutefois pas présenter de défauts cognitifs majeurs dans le bassin de Morris en conditions normales. Toutefois, en conditions de jeûne, elles tendent à une meilleure mémorisation à court terme. Les études morphologiques et histologiques au niveau cardiaque n'ont pas révélé de d'hypertrophie au niveau ventriculaire. La stimulation de la contraction à l'isoprotérénol n'a pas mis en évidence de défaut d'adaptation des coeurs GLUT8-/-. Cependant l'analyse fonctionnelle par électrocardiogramme, en conditions basales, a montré une augmentation de la durée de l'onde P, suggérant un défaut dans la dépolarisation des oreillettes. Nos résultats indiquent que GLUT8 ne joue pas un rôle prédominant dans la survie et la fonction basale des souris. Il pourrait jouer un rôle plus important dans des situations stressantes pour l'organisme, comme l'hypoglycémie ou les conditions d'ischémie qui induiraient son expression à la membrane plasmique et stimuleraient le captage du glucose. Abstract GLUT8 was the first of the recently identified isoform of the GLUT family proteins. It is strongly expressed in the testis. It is also found at a lower level in the blastocyst, in heart and in the brain. Under basal conditions, it is retained in the intracellular compartment, but when the internalization motif dileucine is mutated, GLUT8 translocates to the plasma membrane and transports glucose with a relatively high affinity. To study its function in vivo, we created a conditional knock out mouse model. To do so, we targeted the last exon of the GLUT8 gene with two loxP sites. We then crossed these mice with a transgenic model expressing the cre-recombinase in the gem' line to generate a constitutional total knock out mouse. The statistics made on the first breedings showed that some of the knock out mice do not survive, suggesting a role of GLUT8 in the embryonic development. Conversely mice who survive do not show developmental defects and they are fertile with normal glucose and insulin blood levels. In the brain, the general structure of the hippocampus is not modified by the deletion of GLUT8. However, GLUT8-/- mice show an increase in the cell proliferation in the dentate gyms. This cell proliferation could be due to an increase in the cell death in the hippocampus. When tested in the morris water maze, these mice do not show any cognitive defects in the basal conditions, but they have a tendency to learn better in fasted conditions. The morphological and histological studies made at the heart level did not show any cardiac hypertrophy in the ventricles. The stimulation with isoproterenol did not show any adaptation defects in the GLUT8-/- hearts. However, the functional analysis made in basal conditions with the electrocardiogram showed an increase in the P wave length, suggesting a defect in the atrial depolarization in the knock out mice. Overall, our results show that GLUT8 does not play an important role in the basal general functions in the mice, but might play a more important role during whole organism stress. Hypoglycaemia or ischemia, for example could stimulate the GLUT8 translocation to the plasma membrane to increase specifically glucose uptake. Résumé tout public Les différentes cellules de l'organisme possèdent des propriétés particulières, qui leur permettent de maintenir les fonctions de l'organe auquel elles appartiennent. La membrane plasmique qui les délimite sélectionne les substances qui vont pénétrer à l'intérieur de la cellule et permet ainsi de maintenir un environnement interne constant. Le glucose est une source d'énergie importante pour la cellule et doit pouvoir pénétrer à l'intérieur de la cellule. Il utilise pour cela des protéines de transport qui le feront passer de part et d'autre de la membrane. Les protéines de la famille des GLUT (pour GLUcose Transporter) possèdent cette capacité. GLUT8 est un membre de la famille des GLUT identifié récemment. Il possède la capacité de transporter le glucose quand il se présente à la surface de la cellule. Il est principalement exprimé dans les testicules, dans le coeur et le cerveau et durant le développement embryonnaire. Son rôle n'est toutefois pas encore défini. Ce travail consiste à étudier la fonction de GLUT8 au niveau de l'organisme entier. Nous avons créé un modèle de souris dans lesquelles l'expression de GLUT8 a été supprimée pour mettre en évidence son importance dans le maintien de l'intégrité des fonctions du corps. Les observations effectuées sur les souris qui n'expriment plus GLUT8 nous indiquent que leurs cellules prolifèrent plus vite au niveau de l'hippocampe. L'hippocampe est une structure située dans le cerveau qui est impliquée dans les phénomènes d'apprentissage. Les souris qui ont été testées dans des tâches d'apprentissage n'ont malgré cela pas montré une amélioration de la mémorisation. Dans le coeur, la suppression de GLUT8 semble présenter un défaut quand on mesure l'activité électrique du coeur par électrocardiogramme. Toutefois, ils fonctionnent normalement et ne présentent pas de défauts morphologiques en conditions normales. Les expériences effectuées sur les modèles de souris indiquent que GLUT8 ne jouerait pas un rôle prédominant dans le fonctionnement normal du corps. Il pourrait exercer sa fonction dans des situations plus particulières comme l'hypoglycémie, où il permettrait une meilleure capacité à transporter le glucose dans les cellules.

Difficulties associated with out-patient management of drug abusers by general practitioners. A cross sectional survey of general practitioners with and without methadone patients in Switzerland

Résumé de l'article Contexte : En Suisse, les médecins de premier recours traitent la plupart des patients dépendants aux opiacés méthadone en tant que traitement de substitution. Méthode : Nous avons étudié les difficultés rencontrées dans la prise en charge des patients toxicodépendants en envoyant par poste un questionnaire d'enquête. Nous avons envoyé ce questionnaire à tous les médecins de premier recours de Suisse Romande prescrivant de la méthadone (556 médecins). Nous avons envoyé un autre questionnaire, plus court, à des médecins de premier recours du Canton de Vaud qui ne prescrivent pas de méthadone. Résultats : le taux de réponse global est de 63,3 %. La plus haute dose de méthadone donnée par les médecins de premier recours est de 120,4 mg/j (moyenne). Questionnés au sujet de l'aide qu'ils désireraient recevoir face à ces patients, les médecins de premier recours avec patients substitués par méthadone ont mentionné premièrement l'importance d'un meilleur remboursement des services prodigués. Les autres éléments demandés ont été une meilleure formation, de meilleures connaissances des pathologies psychiatriques et des groupes de discussion de cas cliniques. Les médecins sans patients sous méthadone refusent de traiter ces patients surtout pour des raisons émotionnelles et relationnelles. En conclusion : les médecins acceptant des patients sous méthadone rencontrent des difficultés relationnelles et émotionnelles. Ils désirent un meilleur remboursement pour les services prodigués.

Prevention of atelectasis formation during the induction of general anesthesia in morbidly obese patients

Résumé: La formation des atélectasies durant l'induction de l'anesthésie générale est plus importante chez le patient obèse morbide. Nous avons démontré dans des travaux de recherche antérieurs que l'utilisation de la PEEP (Pression Positive en Fin d'Expiration) durant l'induction de l'anesthésie prévient la formation d'atélectasies chez des patients non obèses. Par conséquent, nous voulions étudier l'efficacité de la pression positive en fin d'expiration chez le patient obèse morbide dans la prévention de la formation d'atélectasies. Nous avons fait une étude de 23 patients obèses morbides (BMI > 35 kg / m2) dans 2 groupes. Dans le groupe utilisant la pression positive en fin d'expiration, les patients respiraient 100% d'oxygène pendant 5 minutes par l'intermédiaire d'un masque facial type CPAP avec une pression de 10 cm H20. Après l'induction de l'anesthésie, nous avons ventilé les patients au masque facial avec une PEEP de 10 cm H20. Dans le groupe de contrôle, nous avons procédé au même type d'induction sans utiliser la pression positive en fin d'expiration. La surface de poumon atélectatique a été évaluée par tomographie (CT scann). L'étude des échanges gazeux se faisait à 2 reprises, à partir de gazométries réalisées juste avant l'induction de l'anesthésie puis juste après l'intubation. Après l'induction de l'anesthésie et l'intubation, les patients du groupe de contrôle présentaient une quantité d'atélectasies plus importante que les patients du groupe où la PEEP avait été utilisée (10.4% + 4.8% dans le groupe de contrôle versus 1.3% dans le groupe utilisant la pression positive en fin d'expiration p < 0.001). Après l'intubation, en présence d'une fraction inspirée en oxygène à 100%, la Pa02 était significativement supérieure dans le groupe ayant utilisé la pression positive en fin d'expiration en comparaison avec le groupe de contrôle (respectivement 457 ± 130 mmHg versus 315 ± 100 mmHg). Nous avons conclu que chez le patient obèse morbide, le recours à la pression positive en fin d'expiration lors de l'induction de l'anesthésie permet de prévenir largement la formation d'atélectasies et s'accompagne d'une meilleure oxygénation. Abstract: Atelectasis caused by general anesthesia is increased in morbidly obese patients. We have shown that application of positive end-expiratory pressure (PEEP) during the induction of anesthesia prevents atelectasis formation in nonobese patients. We therefore studied the efficacy of PEEP in morbidly obese patients to prevent atelectasis. Twenty-three adult morbidly obese patients (b ody mass index >35 kg/m2) were randomly assigned to one of two groups. In the PEEP group, patients breathed 100% oxygen (5 min) with a continuous positive airway pressure of 10 cm H20 and, after the induction, mechanical ventilation via a face mask with a PEEP of 10 cm H2O. In the control group, the same induction was applied but without continuous positive airway pressure or PEEP. Atelectasis, determined by computed tomography, and blood gas analysis were measured twice: before the induction and directly after intubation. After endotracheal intubation, patients of the control group showed an increase in the amount of atelectasis, which was much larger than in the PEEP group (10.4% -± 4.8% in control group versus 1.7% ± 1.3% in PEEP group; P <0.001). After in.tubation with a fraction of inspired oxygen of 1.0, Pao, was significantly higher in the PEEP group compared with the control group (457 ±- 130 mm Hg versus 315 ± 100 mm Hg, respectively; P = 0.035) We conclude that in morbidly obese patients, atelectasis formation is largely prevented by PEEP applied during the anesthetic induction and is associated with a better oxygenation.

Macronutrient composition of the diet and prospective weight change in participants of the EPIC-PANACEA study.

BACKGROUND The effect of the macronutrient composition of the usual diet on long term weight maintenance remains controversial. METHODS 373,803 subjects aged 25-70 years were recruited in 10 European countries (1992-2000) in the PANACEA project of the EPIC cohort. Diet was assessed at baseline using country-specific validated questionnaires and weight and height were measured at baseline and self-reported at follow-up in most centers. The association between weight change after 5 years of follow-up and the iso-energetic replacement of 5% of energy from one macronutrient by 5% of energy from another macronutrient was assessed using multivariate linear mixed-models. The risk of becoming overweight or obese after 5 years was investigated using multivariate Poisson regressions stratified according to initial Body Mass Index. RESULTS A higher proportion of energy from fat at the expense of carbohydrates was not significantly associated with weight change after 5 years. However, a higher proportion of energy from protein at the expense of fat was positively associated with weight gain. A higher proportion of energy from protein at the expense of carbohydrates was also positively associated with weight gain, especially when carbohydrates were rich in fibre. The association between percentage of energy from protein and weight change was slightly stronger in overweight participants, former smokers, participants ≥60 years old, participants underreporting their energy intake and participants with a prudent dietary pattern. Compared to diets with no more than 14% of energy from protein, diets with more than 22% of energy from protein were associated with a 23-24% higher risk of becoming overweight or obese in normal weight and overweight subjects at baseline. CONCLUSION Our results show that participants consuming an amount of protein above the protein intake recommended by the American Diabetes Association may experience a higher risk of becoming overweight or obese during adult life.

Development and validation of a risk score predicting substantial weight gain over 5 years in middle-aged European men and women.

BACKGROUND Identifying individuals at high risk of excess weight gain may help targeting prevention efforts at those at risk of various metabolic diseases associated with weight gain. Our aim was to develop a risk score to identify these individuals and validate it in an external population. METHODS We used lifestyle and nutritional data from 53°758 individuals followed for a median of 5.4 years from six centers of the European Prospective Investigation into Cancer and Nutrition (EPIC) to develop a risk score to predict substantial weight gain (SWG) for the next 5 years (derivation sample). Assuming linear weight gain, SWG was defined as gaining ≥ 10% of baseline weight during follow-up. Proportional hazards models were used to identify significant predictors of SWG separately by EPIC center. Regression coefficients of predictors were pooled using random-effects meta-analysis. Pooled coefficients were used to assign weights to each predictor. The risk score was calculated as a linear combination of the predictors. External validity of the score was evaluated in nine other centers of the EPIC study (validation sample). RESULTS Our final model included age, sex, baseline weight, level of education, baseline smoking, sports activity, alcohol use, and intake of six food groups. The model's discriminatory ability measured by the area under a receiver operating characteristic curve was 0.64 (95% CI = 0.63-0.65) in the derivation sample and 0.57 (95% CI = 0.56-0.58) in the validation sample, with variation between centers. Positive and negative predictive values for the optimal cut-off value of ≥ 200 points were 9% and 96%, respectively. CONCLUSION The present risk score confidently excluded a large proportion of individuals from being at any appreciable risk to develop SWG within the next 5 years. Future studies, however, may attempt to further refine the positive prediction of the score.

Do socioeconomic inequalities in mortality vary between different Spanish cities? a pooled cross-sectional analysis.

BACKGROUND The relationship between deprivation and mortality in urban settings is well established. This relationship has been found for several causes of death in Spanish cities in independent analyses (the MEDEA project). However, no joint analysis which pools the strength of this relationship across several cities has ever been undertaken. Such an analysis would determine, if appropriate, a joint relationship by linking the associations found. METHODS A pooled cross-sectional analysis of the data from the MEDEA project has been carried out for each of the causes of death studied. Specifically, a meta-analysis has been carried out to pool the relative risks in eleven Spanish cities. Different deprivation-mortality relationships across the cities are considered in the analysis (fixed and random effects models). The size of the cities is also considered as a possible factor explaining differences between cities. RESULTS Twenty studies have been carried out for different combinations of sex and causes of death. For nine of them (men: prostate cancer, diabetes, mental illnesses, Alzheimer's disease, cerebrovascular disease; women: diabetes, mental illnesses, respiratory diseases, cirrhosis) no differences were found between cities in the effect of deprivation on mortality; in four cases (men: respiratory diseases, all causes of mortality; women: breast cancer, Alzheimer's disease) differences not associated with the size of the city have been determined; in two cases (men: cirrhosis; women: lung cancer) differences strictly linked to the size of the city have been determined, and in five cases (men: lung cancer, ischaemic heart disease; women: ischaemic heart disease, cerebrovascular diseases, all causes of mortality) both kinds of differences have been found. Except for lung cancer in women, every significant relationship between deprivation and mortality goes in the same direction: deprivation increases mortality. Variability in the relative risks across cities was found for general mortality for both sexes. CONCLUSIONS This study provides a general overview of the relationship between deprivation and mortality for a sample of large Spanish cities combined. This joint study allows the exploration of and, if appropriate, the quantification of the variability in that relationship for the set of cities considered.

Association of HbA1c and cardiovascular and renal disease in an adult Mediterranean population

BACKGROUND: Increasing evidence suggests a mechanistic link between the glycemic environment and renal and cardiovascular events, even below the threshold for diabetes. We aimed to assess the association between HbA1c and chronic kidney disease (CKD) and cardiovascular disease (CVD). METHODS: A cross-sectional study involving a random representative sample of 2270 adults from southern Spain (Malaga) was undertaken. We measured HbA1c, serum creatinine and albuminuria in fasting blood and urine samples. RESULTS: Individuals without diabetes in the upper HbA1c tertile had an unfavorable cardiovascular and renal profile and shared certain clinical characteristics with the patients with diabetes. Overall, a higher HbA1c concentration was strongly associated with CKD or CVD after adjustment for traditional risk factors. The patients with known diabetes had a 2-fold higher odds of CKD or CVD. However, when both parameters were introduced in the same model, the HbA1c concentration was only significantly associated with clinical endpoints (OR: 1.4, 95% CI, 1.1-1.6, P = 0.002). An increase in HbA1c of one percentage point was associated with a 30% to 40% increase in the rate of CKD or CVD. This relationship was apparent in persons with and without known diabetes. ROC curves illustrated that a HbA1c of 37 mmol/mol (5.5%) was the optimal value in terms of sensitivity and specificity for predicting endpoints in this population. CONCLUSION: HbA1c levels were associated with a higher prevalence of CKD and CVD cross-sectionally, regardless of diabetes status. These data support the value of HbA1c as a marker of cardiovascular and renal disease in the general population.

Forest fires cluster detection with space-time scan statistics

Forest fires are defined as uncontrolled fires often occurring in wildland areas, but that can also affect houses or agricultural resources. Causes are both natural (e.g.,lightning phenomena) and anthropogenic (human negligence or arsons).Major environmental factors influencing the fire ignition and propagation are climate and vegetation. Wildfires are most common and severe during drought period and on windy days. Moreover, under water-stress conditions, which occur after a long hot and dry period, the vegetation is more vulnerable to fire. These conditions are common in the United State and Canada, where forest fires represent a big problem. We focused our analysis on the state of Florida, for which a big dataset on forest fires detection is readily available. USDA Forest Service Remote Sensing Application Center, in collaboration with NASA-Goddard Space Flight Center and the University of Maryland, has compiled daily MODIS Thermal Anomalies (fires and biomass burning images) produced by NASA using a contextual algorithm that exploits the strong emission of mid-infrared radiation from fires. Fire classes were converted in GIS format: daily MODIS fire detections are provided as the centroids of the 1 kilometer pixels and compiled into daily Arc/INFO point coverage.

Epidemiology and antifungal susceptibility of bloodstream fungal isolates in pediatric patients: a Spanish multicenter prospective survey.

Data on fungemia epidemiology and antifungal susceptibility of isolates from children are scarce, leading frequently to pediatric empirical treatment based on available adult data. The present study was designed to update the epidemiological, mycological, and in vitro susceptibility data on fungal isolates from children with fungemia in Spain. All fungemia episodes were identified prospectively by blood culture over 13 months at 30 hospitals. Tests of susceptibility to amphotericin B, flucytosine, fluconazole, itraconazole, posaconazole, voriconazole, anidulafungin, caspofungin, and micafungin were performed at participant institutions by a microdilution colorimetric method. New species-specific clinical breakpoints for fluconazole, voriconazole, and echinocandins were also applied. A total of 203 episodes of fungemia in 200 children were identified. A higher proportion of fungal isolates was from general wards than intensive care units (ICU). Candida parapsilosis (46.8%), Candida albicans (36.5%), Candida tropicalis (5.9%), Candida glabrata (3.9%), and Candida guilliermondii (2.5%) were the leading species. C. parapsilosis was the predominant species except in neonates. C. albicans was the most frequent in neonatal ICU settings (51.9%). Intravascular catheter (79.3%), surgery (35%), prematurity (30%), and neutropenia (11%) were the most frequent predisposing factors. Most Candida isolates (95.1%) were susceptible to all antifungals. When the new species-specific clinical breakpoints were applied, all C. parapsilosis isolates were susceptible to echinocandins except one, which was micafungin resistant. This is the largest published series of fungemia episodes in the pediatric setting. C. parapsilosis is the most prevalent species in Spain, followed by C. albicans and C. tropicalis. Resistance to azole and echinocandin agents is extremely rare among Candida species. The fluconazole resistance rate in Spain has decreased in the last 10 years.

Qualité des statistiques de causes de décès: problèmes actuels et perspectives. [Quality of statistics on causes of death: current problems and perspectives].

Statistics of causes of death remain an important source of epidemiological data for the evaluation of various medical and health problems. The improvement of analytical techniques and, above all, the transformation of demographic and morbid structures of populations have prompted researchers in the field to give more importance to the quality of death certificates. After describing the data collection system presently used in Switzerland, the paper discusses various indirect estimations of the quality of Swiss data and reviews the corresponding international literature.

Nuevos datos sobre fibrilación auricular, observaciones al estudio OFRECE. Respuesta

We appreciate the interest shown by Vidal-Pérez et al. in our article published recently in Revista Española de Cardiología,1 which provides us with an opportunity to present some interesting additional information not included in the article itself. We agree on the importance of knowing the thromboembolic risk of the population included in the OFRECE study, both for patients with a diagnosis of atrial fibrillation and for the general population. In our study, the mean (standard deviation) CHADS2 and CHAD2DS2-VASc of patients with atrial fibrillation was 2.3 (1.3) and 3.8 (1.6), respectively. In the general population, the mean (standard deviation) CHADS2 and CHAD2DS2-VASc of patients with atrial fibrillation was 0.8 (1) and 1.8 (1.5), respectively. The distribution of both scales is in agreement with that of the Val-FAAP and AFABE studies,2, 3 although the similarity is greater in the 2 population-based studies (Figure). These data are, we believe, relevant because they show that the level of risk in the population with atrial fibrillation is very similar to that of the populations included in clinical trials with new oral anticoagulants. In addition, an increasing body of evidence suggests that thromboembolic risk, as measured with these scales in the population without a diagnosis of atrial fibrillation, is associated with the onset of events.

All-cause mortality in the cohorts of the Spanish AIDS Research Network (RIS) compared with the general population: 1997-2010.

BACKGROUND Combination antiretroviral therapy (cART) has produced significant changes in mortality of HIV-infected persons. Our objective was to estimate mortality rates, standardized mortality ratios and excess mortality rates of cohorts of the AIDS Research Network (RIS) (CoRIS-MD and CoRIS) compared to the general population. METHODS We analysed data of CoRIS-MD and CoRIS cohorts from 1997 to 2010. We calculated: (i) all-cause mortality rates, (ii) standardized mortality ratio (SMR) and (iii) excess mortality rates for both cohort for 100 person-years (py) of follow-up, comparing all-cause mortality with that of the general population of similar age and gender. RESULTS Between 1997 and 2010, 8,214 HIV positive subjects were included, 2,453 (29.9%) in CoRIS-MD and 5,761 (70.1%) in CoRIS and 294 deaths were registered. All-cause mortality rate was 1.02 (95% CI 0.91-1.15) per 100 py, SMR was 6.8 (95% CI 5.9-7.9) and excess mortality rate was 0.8 (95% CI 0.7-0.9) per 100 py. Mortality was higher in patients with AIDS, hepatitis C virus (HCV) co-infection, and those from CoRIS-MD cohort (1997-2003). CONCLUSION Mortality among HIV-positive persons remains higher than that of the general population of similar age and sex, with significant differences depending on the history of AIDS or HCV coinfection.

Sobremortalidad por cáncer en El Campo de Gibraltar. El medio social, la piedra clave

Vol. 1 del proyecto de investigación: "La sobremortalidad por cáncer en El Campo de Gibraltar. Mirar el pasado para explicar el presente".

Advance directives and the impact of timing. A qualitative study with Swiss general practitioners.

PRINCIPLES: Advance directives are seen as an important tool for documenting the wishes of patients who are no longer competent to make decisions in regards to their medical care. Due to their nature, approaching the subject of advance directives with a patient can be difficult for both the medical care provider and the patient. This paper focuses on general practitioners' perspectives regarding the timing at which this discussion should take place, as well as the advantages and disadvantages of the different moments. METHODS: In 2013, 23 semi-structured face-to-face interviews were performed with Swiss general practitioners. Interviews were analysed using qualitative content analysis. RESULTS: In our sample, 23 general practitioners provided different options that they felt were appropriate moments: either (a) when the patient is still healthy, (b) when illness becomes predominant, or (c) when a patient has been transferred to a long-term care facility. Furthermore, general practitioners reported uncertainty and discomfort regarding initiating the discussion. CONCLUSION: The distinct approaches, perspectives and rationales show that there is no well-defined or "right" moment. However, participants often associated advance directives with death. This link caused discomfort and uncertainty, which led to hesitation and delay on the part of general practitioners. Therefore we recommend further training on how to professionally initiate a conversation about advance directives. Furthermore, based on our results and experience, we recommend an early approach with healthy patients paired with later regular updates as it seems to be the most effective way to inform patients about their end-of-life care options.